Provider Demographics
NPI:1588644892
Name:JEFFREY J HICKS DPM PC
Entity Type:Organization
Organization Name:JEFFREY J HICKS DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM PC
Authorized Official - Phone:847-336-3020
Mailing Address - Street 1:15 TOWER CT
Mailing Address - Street 2:STE 250
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-336-3020
Mailing Address - Fax:847-336-3318
Practice Address - Street 1:15 TOWER CT
Practice Address - Street 2:STE 250
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-336-3020
Practice Address - Fax:847-336-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004968213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04926843OtherBCBS
ILDD4677OtherRAILROAD MEDICARE
IL4481570001OtherNATIONAL GOVERNMENT SERVICES
IL016004968Medicaid
IL211632Medicare ID - Type Unspecified
U72298Medicare UPIN
IL4481570001Medicare NSC